A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Activity intolerance.

Fluid volume excess.

Ineffective airway clearance.

Altered nutrition; less than body requirements.

Answer and Explanation

The Correct Answer is C

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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Correct Answer is B

Explanation

Choice A reason: Leg numbness is not a typical symptom of thyroid dysfunction and may be related to other conditions such as peripheral neuropathy.

Choice B reason: Cold sensitivity is a common symptom of hypothyroidism and warrants evaluation of thyroid function.

Choice C reason: Slow weight loss is not a typical symptom of thyroid dysfunction; unexplained weight gain is more indicative of hypothyroidism.

Choice D reason: Muscle weakness can be associated with various conditions, but cold sensitivity is more specific to thyroid issues.

A. Monitor daily sodium intake. B. Measure ankle circumference. C. Obtain serum creatinine levels daily. D. Ensure client takes a diuretic every morning.

Correct Answer is A

Explanation

Choice A reason: Monitoring daily sodium intake is crucial because SIADH often leads to hyponatremia (low sodium levels). Keeping track of sodium intake helps manage and prevent complications associated with sodium imbalances, such as seizures or confusion.

Choice B reason: Measuring ankle circumference can help assess fluid retention, but it is not the first intervention. It is more important to address the underlying issue of sodium imbalance.

Choice C reason: Obtaining serum creatinine levels daily can provide information about kidney function but does not directly address the immediate concern of sodium and fluid balance in SIADH.

Choice D reason: Ensuring the client takes a diuretic every morning may be part of the treatment plan, but it is more important to first monitor and manage sodium levels to ensure safe and effective use of diuretics.

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A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

Correct Answer is B

Explanation

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

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